Hematologic Oncology Update, Issue 3, 2016 (Video Program) - Video 19Case discussion: A 36-year-old woman with relapsed/refractory acute lymphoblastic leukemia achieves complete remission with blinatumomab
3:22 minutes.
TRANSCRIPTION:
DR TIBES: That was actually a very fascinating case, a 36-year-old female, newly diagnosed, PH-negative ALL. She underwent a pediatric-inspired modeled induction regimen after the Intergroup trial. It’s important that younger patients, up to the age of 40 or 45, are really treated with more intensive pediatric-style ALL regimen. The patient was doing well initially but unfortunately did not achieve a remission after the first cycle and was refractory after the second cycle. Then we discussed various salvage regimens, but they’re not that good. And then we discussed blinatumomab, because blinatumomab is a CD19-positive — sorry — blinatumomab is a bispecific antibody. It’s a fascinating drug. So essentially you attract immune cells, or T cells, to the CD19-positive ALL cells. And then you initiate a direct cell killing. And this patient was started on blinatumomab. And blinatumomab side effects, you can see neurological side effects. This patient actually did complain of some kind of visual disturbances, mild confusion, being off. And we held the therapy. And she was very afraid and very scared of continuing therapy. So we stopped the therapy for 16 or 18 hours, and after many conversations, we eventually restarted her, or we gave her dexamethasone, redosed her with dex, higher dosages. We slowed down the infusion and continued blinatumomab. And she tolerated the infusion well and is in remission currently and now can go to an allogeneic stem cell transplantation. So it’s really counseling of the patient with side effects of this new medication and observing them closely. And it was very rewarding — over the weekend, after many hours of talking to her, she finally agreed to continue therapy and is doing well. DR LOVE: That’s awesome. DR TIBES: So we now have a drug with blinatumomab that actually can achieve remission in patients, refractory ALL, in a very high percentage, as well as there’s good data now, emerging data, that blinatumomab can convert MRD-positive disease to MRD-negative disease. So maybe to finish up, MRD, or minimal residual disease, monitoring is very important in ALL. And I encourage all of my colleagues to send it out, not just fall in morphological remission, but we also want to see MRD remissions. So that’s similar to CML, where we measure BCR-ABL. We have various ways of measuring, by flow or by PCR, measuring MRD for ALL. DR LOVE: What is the spectrum of complications that you see with blinatumomab? DR TIBES: We do see some cytopenias. And we do see infusional-related — particularly initially, a cytokine release syndrome. Most of your form of that is including neurological side effects. In the most severe, seizures in a few percentage of the patients. So patients are in the hospital. You need to start slow for the first 7 days. And then you can increase the dose. It’s a continuous infusion. Patients need to wear a pump. But after the first 9 to 10 days with dose-increased levels, where they need to be in the hospital, they can actually receive it as an outpatient and do quite well. |